Sample Final Project in Nursing-Creation of a Nursing Process
Introduction
Being the smallest unit of a society, family knowledge and comprehension is the initial step towards family nursing practice. This paper makes reference to an extended family of multigenerational type. The family is composed of nuclear family and blood relatives-extended; and consists of three generations-multigenerational. The ages of the father and the mother are 45 and 39 respectively. They have been married for the past 20-years and blessed with 4 children, 3-males and 1-female, the last born. The ages of the children in a descending order are as follows: 24, 20, 14 and 9. The paternal grandfather aged 67, and the paternal grandmother aged 65 whose energies are waning stay with the family.
The mother is a graduate from a local University in Canada and works as an accountant in a high school. The father is a high school drop-out, a business man and owns rental apartments. All the children are schooling. The family has health insurance for all the members which they have paid up to 18-months in advance. They are African-Americans and of Christian background. The father is responsible for paying school fee and health insurance coverage while the mother buys food for the household.
Assessment
General Lifestyle
The mother works from Monday to Friday and only interacts with the children after work or on weekends. The father being self-employed only attends to his businesses when called. The two elder children are in college and comes back home after every 2 months for holidays while the two younger ones are in grade 8 and grade 4 respectively. The grandfather moves around using forearm crutches while the grandmother can walk. They have a house helper who helps with cooking, cleaning and washing clothes. Even though a gym hall is located a few miles away, they rarely attend. The mother attends the gym once in a month but goes for health walks every weekend. The father attends the gym twice a month.
Health Risk Appraisal
The grandfather is diabetic and his leg was amputated 2 years before he began staying with the family due to diabetic foot (reason for walking with crutches). The grandmother was diagnosed of hypertension at age 57 and is on anti-hypertensive drugs. The grandparents’ bedrooms are upstairs and have to walk downstairs every morning by the help of another person. 3-years ago, the father felt frequently thirsty, and had increased urine frequency. His friend advised him to go for diabetes screening which later expedited to his diagnosis of Type 2 Diabetes Mellitus. Even though he affords the drugs, he reports sometimes he misses the medications while he goes for seminars and workshops. Further, he rarely goes for routine blood glucose monitoring. The mother and the children are healthy. The maternal grandmother died of breast cancer therefore; this makes the mother at risk of breast cancer.
Perceived Degree of Control over Health Status
Both the parents have attained a level of education that enables them to have excellent health knowledge. This is evident on the father’s action to go for diabetes screening. The mother is aware that she is at risk of breast cancer and has talked with her doctor regarding screening. Being that they have health insurance coverage, the parents take their grandparents for regular check-up monthly. Further, they ensure the grand parents take their medications as scheduled. The family stays peacefully and reports not having any disputes in the past. They are in good relationship with the community, church and have no forensic history.
Physical and Mental Illness
The summary of the medical conditions in the family are as follows: the grandfather is diabetic and physically debilitated-has an amputated leg while the grandmother is hypertensive. The father is diabetic while the mother and the children are healthy. The mother has been recently complaining of headache. Being that she works from Monday to Friday, and three quarter of her job involves working on computer, she is likely to have tension headache. The grandfather, due to his age has been having memory problems and cognitive disorientation. Recently, the mother is restless and irritable and reports having an inflexible employer.
Stress Levels
The mother has been complaining about her boss. She reports that her boss is rigid and demands things done in his own way. The boss has attracted enmity from his employees and some have resigned. She reports that the boss demands them to report strictly at 8 in the morning and leave the office not earlier than 5 in the evening, failure of which leads to disciplinary actions. Her tension headache and anxiety (restlessness and irritability) can be attributed to the long hours of work and the inordinate work.
Environmental Stressors
Despite having a house helper, the mother uses an alarm to wake up at 5:30 am to help in doing the house chores and prepare for work. She reports the loud noise from the alarm irritates her. Further, the family reports having a teenager neighbor who plays loud music at night disturbing their sleep.
Chemical/Substance Usage
The grandfather has a longstanding history of smoking cigarettes. He started smoking at age 35, 3 cigarettes per day. He has smoked for 32 years and has 4.8 packs per year. He does not drink alcohol. The father takes at least two bottles of beer per day and do not smoke cigarettes. In the morning, the family either uses caffeine or tea. The mother and the grandmother do not drink or smoke.
General Health Status
In most cases, life expectancy is used as measure of general health status (Gourevitch et al., 2019). The family comes from a community where age limit is placed at 75 years. Physical unhealthy days increase with age as evidenced in the family. Mental comorbidities also increase with age and with psychosocial stressors. This is also evident in the family. Moreover, limitation of activities increases with age. Common chronic diseases in the community include diabetes, cardiovascular diseases, cancer and arthritis. The entire family has history of diabetes, hypertension and cancer.
Summary
The family of interest is extended and of multigenerational type-three generations are present. They are of African-American descent. Both parents are working thence, the family is financially stable. The four children are all schooling. There is a family history of diabetes (grandfather and the father), hypertension (paternal grandmother) and breast cancer (maternal grandmother). Further, the mother complains of stress at work place and is restless and irritable recently. The grandfather has a long standing history of smoking while the father drinks alcohol.
Nursing Diagnosis Statements
Considering the family as a client, the following nursing diagnosis befits the father, mother and the grandfather respectively: risk for unstable serum glucose evidenced by inability to strictly comply to medications and lack of routine serum glucose monitoring (father); anxiety related to stress at work as evidenced by restlessness, irritability and recurrent tension headaches (mother); risk for fall associated with advanced age, impaired physical mobility and cognitive dysfunction (grandfather).
The father is diabetic however, due to frequent attendance of workshops and seminars; he misses his medications and rarely goes for glucose monitoring. According to Danne et al. (2017), Type 2 diabetic patients should take the serum glucose readings at least once a day. The mother complains of her employer’s rigidity which translates to the stress at work. This explains her raised anxiety levels. Symptoms of anxiety include agitation, irritability, fearfulness and motoric symptoms such as restlessness and tremors (Chand & Marwaha, 2020). The mother presents with three symptoms including tension headache, irritability and restlessness. Further, the grandfather being elderly, with a physical disability and cognitive dysfunction has a risk of fall. In patients above the age of 65, falls are a major cause of injuries and death (Alshammari et al., 2018). The grandfather is 67 years of age and vulnerable to fall over the stairs. Prevention strategies are therefore vital.
Outcome Criteria
The desired outcome in the diabetic patient (father) is to maintain the pre-prandial glucose between the ranges of 90-130 mg/dl and keep the hemoglobin A1C levels below 7%. This outcome is in line with the primary goal of management of diabetes which involves prevention of hyperglycemia. Hemoglobin A1C is a measure of glycemic control (American Diabetes Association, 2019). Higher levels of hemoglobin A1C translates to poor glycemic control thus higher chances of complications. The other outcome in managing this patient includes education on the risk factors of hyperglycemia. The risk factors include lack of medication adherence, infections, use of steroids, failure to adhere to diabetic eating plan and physical inactivity (ADA, 2019). Educating the patient on these factors makes encourages preventive strategies.
Concerning the mother, desired outcomes includes increasing the patients’ psychological comfort, and encouraging her to verbalize her causative and coping factors. The patient from the family case study is obviously anxious as explained by the restlessness and irritability. Further, she presents with tension headache, a manifestation of her stressful life events and the inflexible employer. The best goal of management of this patient includes exonerating her from the psychosocial and environmental stressors. Further, patients who verbalize their etiologic factors have been proven to have a sigh of relief (Chand & Marwaha, 2020). Enabling the patient to talk about her condition is itself therapeutic (Chand & Marwaha, 2020).
The grandfather is elderly and therefore requires significant support from the family. The desired outcomes that are in line with his nursing diagnosis are as follows: he will not be able to sustain any fall and related injuries; the caregivers (the father and the mother) will be able to implement preventive and safety strategies. In a population, the elderly are considered a special group that requires close monitoring.
The elderly patients are prone to both physical and psychological medical conditions (Kossek et al., 2019). Further, Kossek et al. (2019) denote that various environmental factors put elderly patients at risk of injuries. Examples of the factors include the house ergonomics and steep stairs (Kossek et al., 2019). The prevalence of injuries is higher in elderly patients with physical disabilities such as amputated legs and mental conditions such as epilepsy (Kossek et al., 2019).
Nursing Interventions
To ensure pre-prandial glucose is maintained between 90-130 mg/dl, the following interventions are necessary. Administration of oral hypoglycemic drugs, for example Metformin 500mg twice a day is vital. This intervention prevents fluctuation of serum glucose to extreme high levels. Further, educating the patients on the importance of continuous glucose monitoring is a favorable step. Even though the patient is educated and has adequate health knowledge, he still misses medications and rarely monitors his serum blood glucose. ADA (2019) puts emphasis on the importance of glucose monitoring as a way of preventing complications. The third intervention includes explaining to the patient the importance of a diabetic eating plan. According to ADA (2019), diabetic patients should have three meals that are evenly spaced, 5-6 hours apart.
To achieve the second goal (education on risks of hyperglycemia), the following interventions are essential. Educating the patient on the importance of drug adherence prevents future recurrences of hyperglycemia. Further, teaching the patient on the significance of exercises is also vital. Exercise lowers serum glucose levels and has been associated with decreased body insulin resistance (ADA, 2019). Additional intervention includes reviewing the exercise plan of the patient and assisting the patient lead a physically fit life.
Interventions directed towards management of anxiety include pharmacotherapy and non-pharmacotherapy. The first intervention directed towards the first desired outcome (improving patient’s psychosocial comfort) is to create a rapport with the patient to lower the tension and to create a peaceful interaction. Further, familiarize the patient with the surrounding, an intervention directed to make the patient comfortable and to decrease the anxiety levels. The third intervention includes treating the anxiety using medications such as benzodiazepines. In this case, 10 mg of Diazepam is administered 6 hourly per oral (Chand & Marwaha, 2020).
The second desired outcome in management of the anxiety included encouraging the patient to verbalize her causative and coping strategies. Interventions directed towards achieving this include helping the patient identify the causative factors. In this case, the patient reports stressful events at work. Further, helping the patient identify three best coping mechanisms is essential. Examples of anxiety coping strategies include breathing exercises, self-talks and proper planning of time (Chand & Marwaha, 2020). Additional intervention includes consulting a psychiatrist to manage the patient.
Lastly, to prevent that grandfather from falling, the house helper or any other responsible person should walk him downstairs. Further, the bedrooms for the grandparents should be transferred to ground floor. Additionally, appropriate devices for ambulation should be procured by the family. To implement preventive and safety strategies, the family or the caregivers should ensure adequate lighting on the stairs and the grandparents’ rooms. Further, the family should ensure all their needs are available upstairs. An additional safety mechanism includes consulting a physiotherapist to help the patient gain physical mobility.
Evaluation
The short term evaluation for the first intervention directed towards management of diabetes include making phone calls to confirm adherence to medications while the long term evaluation strategy involves follow up visits to check for blood glucose and hemoglobin A1C levels. The short term evaluation strategy for the second interventions (glucose monitoring) includes use of a glucometer to record blood glucose levels. A remote patient monitoring (RPM) device, for example a glucometer with sensors and Tele-communication devices can be used as a log term strategy. According to Lee, Greenfield and Pappas (2018), use of technology such as RPM has been associated with better glycemic control and improved quality of life. The short term evaluation strategy for the last intervention includes having a record of the patient’s meal per day. Long term assessment depends on the number of times the patient is admitted due to medication induced hypoglycemia.
Concerning the management of anxiety, the first intervention included ensuring a peaceful and a calm interaction. A short term evaluation includes checking the patient’s reaction such as anger and friendliness while a long term evaluation strategy includes continuous monitoring of the patients interaction with her family. Further, a short term evaluation of the patient’s familiarity with the environment includes checking the anxiety and tension level while a long term strategy involves reports from work place-how the patient interacts with her colleagues.
Finally, to evaluate the patient’s willingness to take the drugs, her attitude towards medications is significant. A long term evaluation strategy includes the reports from the family concerning adherence. Further, recurrent attacks of anxiety point towards poor adherence.
Finally, the goals for the safety actions taken to prevent falls from the stairs are as follows: A short term goal includes preventing falls within one week of the implementation of the safety actions. A long term goal includes prevention of the falls within the first and subsequent months. Reports from the family will be significant to nurse in helping determine whether the interventions were appropriate.
Conclusion
A nursing process is essential to a patient care. The contents include assessment, diagnosis, planning, implementation and evaluation. This is a case study of an extended family with three generation. Being that family is essential in nursing practice, assessment of the whole family helps in determining the relationships and interconnectedness within. In family nursing, the connections are crucial in making diagnosis. From the family, the paternal grandfather and the father are diabetic; the paternal grandmother is hypertensive while the mother and the children are healthy. It is evident that genetics is a risk factor for developing diseases. Further, due to various psychosocial stressors, family members are prone to developing various psychiatric conditions. Other than the stressors, age also play a significant role in determining a person’s susceptibility to mental conditions.
References
- Alshammari, S. A., Alhassan, A. M., Aldawsari, M. A., Bazuhair, F. O., Alotaibi, F. K., Aldakhil, A. A., & Abdulfattah, F. W. (2018). Falls among elderly and its relation with their health problems and surrounding environmental factors in Riyadh. Journal of Family & Community Medicine, 25(1), 29–34. https://dx.doi.org/10.4103%2Fjfcm.JFCM_48_17
- American Diabetes Association, ADA. (2019). Standards of Medical Care in Diabetes-2019. USA: ADA.
- Chand, S. P., & Marwaha, R. (2020). Anxiety. In StatPearls. StatPearls Publishing.
- Danne, T., Nimri, R., Battelino, T., Bergenstal, R. M., Close, K. L., DeVries, J. H., Garg, S., Heinemann, L., Hirsch, I., Amiel, S. A., Beck, R., Bosi, E., Buckingham, B., Cobelli, C., Dassau, E., Doyle, F. J., III, Heller, S., Hovorka, R., Jia, W., … Phillip, M. (2017). International consensus on use of continuous glucose monitoring. Diabetes Care, 40(12), 1631–1640. https://doi.org/10.2337/dc17-1600
- Gourevitch, M. N., Athens, J. K., Levine, S. E., Kleiman, N., & Thorpe, L. E. (2019). City-level measures of health, health determinants, and equity to foster population health improvement: The City Health Dashboard. American Journal of Public Health, 109(4), 585–592.
- Kossek, E. E., Thompson, R. J., Lawson, K. M., Bodner, T., Perrigino, M. B., Hammer, L. B., Buxton, O. M., Almeida, D. M., Moen, P., Hurtado, D. A., Wipfli, B., Berkman, L. F., & Bray, J. W. (2019). Caring for the elderly at work and home: Can a randomized organizational intervention improve psychological health? Journal of Occupational Health Psychology, 24(1), 36–54. https://psycnet.apa.org/doi/10.1037/ocp0000104
- Lee, P. A., Greenfield, G., & Pappas, Y. (2018). The impact of telehealth remote patient monitoring on glycemic control in type 2 diabetes: a systematic review and meta-analysis of systematic reviews of randomised controlled trials. BMC Health Services Research, 18(1). https://doi.org/10.1186/s12913-018-3274-8